An Overview of Vascular Surgery

Ahmed Abou-Zamzam, Jr., MD

J. David Killeen, MD

Christian Bianchi, MD (VA)

Theodore Teruya, MD (VA)

Division of Vascular Surgery

Loma Linda University Medical School

Scope of vascular surgery treat all blood vessels in the body (exclusive of the heart). In hospitalized patients, vascular surgeons treat primarily lower extremity ischemia, carotid

artery occlusive disease, and abdominal aortic aneurysms. Most patients with venous

disorders and lymphedema are treated as outpatients.

Chronic Lower Extremity Ischemia

Definition: diminished distal perfusion secondary to obstructive disease

Prevalence: 5% in patients 60-70; 10% in patients 70-80 years old

Pathology: atherosclerotic lesions especially superficial femoral artery occlusion Manifestations: encompasses a spectrum of disease ranging from asymptomatic, to

claudication, to rest pain, to gangrene.

Risk Factors:

Age

Male Sex

Tobacco Use

Diabetes

Hypertension

Hypercholesterolemia

ALL THE SAME AS CORONARY ARTERY DISEASE

Diagnosis:

History claudication, rest pain, ulcers, gangrene? Risk factors Physical Exam always do a complete pulse exam, including 4-limb pressures and ankle- brachial index (ABI) even if the pulses are palpable (Normal ABI 1.0; claudication 0.5-0.9, rest pain 0.3-0.5, gangrene

10-year amputation ~ 11%

Patients with rest pain or ulcers with observation will see ~ 10-20% resolve

Non-operative Treatment:

First line of therapy for patients with claudication is always non-operative:

Smoking cessation will improve walking distance 100-200% within a few months

Daily walking will increase walking distance about 100%

Medications Cilostazol (Pletal) and Pentoxifylline (Trental) improve walking in some individuals, but not to same degree as smoking cessation

and exercise.

Operative Treatment:

Indicated for: gangrene, non-healing ulcers, rest pain, severely limiting

claudication

Type of operation is typically a leg bypass from femoral to popliteal or tibial

arteries; vein graft preferred, prosthetic grafts available (PTFE, Dacron)

May need in-flow with aortobifemoral bypass or axillary-femoral bypass. Rarely, angioplasty +/- stenting is an option.

Post-operative course:

ICU overnight in most; frequent pulse checks; cardiac monitoring

Early ambulation; continue to monitor blood pressure and CBGs; frequent pulse checks

Concerns leg edema common problems; early graft surveillance Results:

5 year limb salvage 90%, graft patency 75% and survival 50%

Aortoiliac Occlusive Disease

Definition:

A sub-category of chronic lower extremity ischemia Pathology:

Atherosclerotic occlusive disease affecting primarily the infrarenal aorta and iliac arteries

Diagnosis:

History similar to above typical patients complain of hip, thigh, and buttock claudication

Leriches syndrome abdominal bruits, absence of femoral pulses, buttock/thigh claudication, and impotence

Physical exam demonstrates quality of femoral pulses, ABIs

Non-invasive testing especially peripheral arterial exam with treadmill Treatment:

Non-operative smoking cessation, daily exercise

Operative aortobifemoral, axillary-femoral, iliac angioplasty +/- stenting, (iliac endarterectomy)

Acute Lower Extremity Ischemia

Definition: Acute diminution in arterial blood flow to an extremity resulting in a

threatened limb (some include any ischemia with duration of less than 2

weeks).

Pathology: Embolic occlusion versus thrombosis of a chronically diseased artery

Native occlusion versus graft occlusion

Diagnosis:

History sudden onset PMH of cardiac disease esp. arrhythmia 6 Ps pain, pallor, pulselessness, paresthesias, poikilothermia, paralysis

Physical exam pulses, viability of extremity key issue is status of opposite limb

Use of arteriography is limited

Treatment:

Heparin once diagnosis is suspected

Surgery of proven benefit Thrombolysis urokinase (no longer available) and tissue plasminogen activator

Results:

Limb salvage achieved in ~ 70-80%

Mortality ~ 15-20% (primarily due to concurrent cardiac disease)

Other Issues in Lower Extremity Ischemia

Atheroemboli Classically from AAA, although although other proximal source possible

(AIOD, CAD)

Popliteal artery aneurysms May present as asymptomatic, acute or chronic lower extremity ischemia

Diabetic foot infections May have foot sepsis with normal arterial circulation

Extracranial Cerebrovascular Disease

Definition: Occlusive disease affecting the extracranial cervical carotid artery most commonly at the carotid bifurcation

Pathology:

Atherosclerotic plaque at carotid bifurcation is most common (area of low

shear)

Other causes include fibromuscular dysplasia and radiation-induced

lesions

Strokes are caused by atheroemboli with or without acute intraplaque

hemorrhage

Low flow is a rare cause of symptoms

Manifestation:

Spectrum includes asymptomatic, amaurosis fugax, transient ischemic attack, and stroke

Risk Factors:

Age, male sex, tobacco use, hypertension, hypercholesterolemia

Diagnosis:

History CVA, TIA, amaurosis fugax; review any risk factors Physical exam carotid bruits (not very useful), heart murmur/arrhythmia, abdominal bruits, signs of lower extremity ischemia

Baseline neurologic exam is essential and fundoscopic exam helpful

Non-Invasive tests carotid duplex can accurately determine degree of stenosis

Invasive tests: angiography used to be the standard but has a risk of stroke

1%. Angiography is reserved for unusual circumstances arch disease, redo, bilateral disease, high lesion

Treatment:

Non-operative aspirin Operative carotid endarterectomy plus aspirin Accepted indications for operation

Asymptomatic disease 60% {ACAS 5.1% vs. 11% at 5 years}

Symptomatic disease 70% {NASCET 9% vs. 26% at 2 years} Likely 50% {NASCET 15.7% vs. 22.2% at 5 years}

Caveat low perioperative CVA and death rate is essential Asymptomatic patients must survive at least 5 years to benefit from a CEA

Operation performed is standard carotid endarterectomy (CEA)

Postoperative course typically includes one day in the hospital

(intermediate care unit)

Intensive blood pressure monitoring and control danger of hemorrhage vs thrombosis and frequent neurologic checks are essential

Patients with fluctuations in BP are at higher risk for perioperative

neurologic events

Fast-tracking now discharge home POD#1

Evolving role for carotid angioplasty and Stenting (CAS)

Currently CAS reserved for high-risk symptomatic >70% stenosis Ongoing trials will likely expand the scope of CAS

Most trials indicate equivalent results CAS versus CEA, with possible

lower cardiac morbidity with CAS, with unclear long-term results.

Results:

5- Year freedom from stroke in symptomatic patients treated with CEA is

87% and in asymptomatic patients is 95%

CEA trades a small up-front risk of stroke for long-term protection from

stroke

Other Issues:

Vertebrobasilar insufficiency difficult to diagnose, ? role of vertebral artery reconstruction

Subclavian-steal a frequent anatomic finding but rarely physiologically significant

Abdominal Aortic Aneurysm

Definition: Localized dilatation of an artery > 1.5 times normal diameter

Use 3.0cm for AAA

Pathology:

Most seen in conjunction with atherosclerosis; ? Genetic influence; ? role

of elastase, metalloproteases, collagenase, infection

Prevalence:

3% in 60-70 year olds; 5% in hypertensive or CAD; 10% in patients with

lower extremity occlusive disease; 20% in patients with first-degree

relative

Risk Factors:

Tobacco 5.57 odds ratio; family history 1.95 OR; diabetes 0.49 OR

Diagnosis:

History 75% of AAA are asymptomatic at diagnosis; most discovered incidentally

Physical exam presence of AAA can be determined only in thin people (waist

Indications for Treatment:

Mortality of a ruptured aneurysm is likely >90%

Only 50% who reach the hospital survive

Most likely never reach the hospital

Elective aneurysm repair carries mortality near 2% in most centers

The time to repair an aneurysm is when risk of rupture > rick of

operation

Observation for small aneurysms ( 5cm in most people

Any symptoms (rupture, emboli, abdominal pain with no other cause)

Rapid enlargement (>1cm in one year)

Associated severe occlusive disease Treatment Options for AAA:

Standard open surgical repair retroperitoneal versus transperitoneal tube graft, aortobiliac or aortobifemoral grafts

Endovascular repair (typically bifurcated stent-grafts AneuRx, Excluder,

Zenith,.)

Endovascular repair is possible in less than half of all AAA, short and medium-term results are equivalent to open repair, long-term

results >5 years are unknown

Pitfalls are endoleaks, device failures, late ruptures, need for life-long follow-up with CT

Post-operative course:

Standard surgery ICU for 1-2 days; often extubated in the operating room, hemodynamic monitoring, fluid resuscitation, monitor urine output

Warning signs anuria and acidosis As always, frequent pulse checks

To ward POD 1, early mobilization, await resolution of ileus (less with

retroperitoneal), home 4-5 days

Stent graft no ICU stay; home POD 2 Results:

Long-term outlook is very good with survival nearly equaling age-

matched cohort

Small risk of anastomatic aneurysms esp. femoral 1% risk of graft infection

Long-term results of stent-grafts remain unknown

Visceral Ischemia Syndromes

Definition: Insufficient perfusion of viscera to maintain normal viability and function.

Pathophysiology:

Most common syndromes account for 95% of instances of visceral

ischemia

Acute embolic mesenteric ischemia (primarily emboli from heart to SMA)

Acute thrombotic mesenteric ischemia (underlying occlusive disease)

Chronic mesenteric ischemia

Non-occlusive mesenteric ischemia (low-flow seen in severe pump failure)

Mesenteric venous thrombosis Diagnosis:

Acute Mesenteric ischemia abrupt onset of severe cramping and periumbilical abdominal pain typically in a patient with a history of cardiac disease

May have explosive, bloody diarrhea (Fever, nausea, vomiting, abdominal

distension may be present)

Classic pain out of proportion to physical findings Arteriography is diagnostic test of choice

Chronic mesenteric ischemia characteristically post-prandial pain, food phobia and weight loss

More common in women

Seen in patients with extensive arteriosclerotic risk factors

Duplex is useful as a screening test

Arteriography is diagnostic test of choice

Treatment:

Acute embolic mesenteric ischemia SMA embolectomy Acute thrombotic mesenteric ischemia visceral bypass

Chronic mesenteric ischemia visceral bypass or transaortic endarterectomy

(Non-occlusive mesenteric ischemia - treat underlying heart disease, may

benefit from intraarterial papaverine; mesenteric venous thrombosis treat with anticoagulation, may need segmental bowel resection)

Results:

Acute mesenteric ischemia mortality close to 50% Chronic mesenteric ischemia mortality 5-10% with good long-term patency, and weight gain

Visceral Ischemia Syndromes

Definition: A spectrum of disease that includes spider telangiectasias, varicose veins,

chronic edema, lipodermatosclerosis, healed ulcers, and active ulcers.

Diagnosis: Physical exam skin changes, spiders, varicose veins, edema, ulcers Document pulses

Accurately record location, size and depth of ulcers (typically in the gaiter

area)

Vascular Lab

Duplex shows anatomic location and can quantify reflux, also can identify deep vein thrombosis

APG venous ejection fraction

PPG venous refill time Classification CEAP Clinical Etiologic Anatomic Pathophysiologic

Treatment:

For ulcers:

Compression will heal virtually all venous ulcers

Local wound care

Antibiotics as needed

?Apligraf

?Role of perforator vein division For spiders and varicose veins:

Office & day surgery

Spider veins sodium morrhuate injections (0.2% & 1.0%)

Subfascial endoscopic perforator surgery

Vericose vein stripping Results:

For ulcers long-term compression therapy is mandatory to prevent ulcer

recurrence

Cosmetic results of sclerotherapy and varicose vein surgery are excellent,

however long-term development of new varicosities and spiders is the rule

Lymphedema

Definition:

Primary

Congenital 10-15%

Praecox (adolescence) 80%

Tarda (>35 years) 10% Secondary

Trauma (esp. post-surgical)

Infection (filariasis), inflammation

Itraabdominal process (tumor rare)

Diagnosis:

Primarily clinical

Exclude severe venous disease with noninvasive tests

Treatment:

Compression, massage therapy

Aggressive treatment of cellulitis (patient with antibiotic prescription)

Goal is early treatment prior to severe skin changes

Results:

Good with a compliant patient

Smoking Cessation

Smoking is the most important risk factor for the development of vascular disease

The addiction is 10X worse than heroin and 20X worse than cocaine

The proper approach to the patient who continues to smoke is:

Repetitive positive encouragement

Stress that cutting down is useless

Encourage his/her partner to be involved

Stress that quitting is a process

Remind patient that recidivism is common and is no reason to give up

Inform the patient that, on average, smoking cessation takes 2-5 years

Successful quitters have an average of 6 episodes of abstinence prior to success

Adjuncts Nicorette, the Patch, Zyban